30. Ritualised nursing behaviour

Key words: Miss Radley, Principal Tutor, Brysson-Whyte, Principal Tutor at Guy's, mock final exams, Southey's tubes, Ward Procedure manual, Isabel Menzies (1959), anxiety amongst nurses, ritualised nursing behaviour, anxiety management, organizational strategies.

Post:

Miss Radley, the Principal Nurse Tutor at Joyce Green Hospital for a good number of years, counted Beatrice Brysson-Whyte, the Principal Tutor at Guy’s Hospital amongst her friends and for this reason Mrs Brysson-Whyte used to come to the Dartford School of Nursing regularly during the 60’s to examine student nurses for the practical part of their SRN mock final exams.

If you can remember those mock practical exams, you will also remember perhaps that the main emphasis of these was on the ability of the would-be SRNs to lay-up examples of some the various trays and trolleys that might be required in caring for the particular patient that one was presented with - in the Practical Room - on the day of the examination care. In addition, one was obviously also expected to able to discuss that patient’s condition and management.

But no matter whether you were asked to lay up a trolley equipped for the insertion of Southey’s tubes (used in the past in the management of lower leg oedema), a trolley for urinary catheterisation or one for some other procedure the focus was always upon the appropriate cleaning of the metal trolley and the comprehensive assembling of all the components that would be required for the selected procedure and the correct presentation of the equipment. This last point seemed to be particularly important because the materials themselves had to be laid out in a prescribed manner following the plans that were contained within the Ward Procedure manual.

Why, I used to wonder, did it matter whether a stainless steel kidney dish was positioned to the right of the article that was pre-destined to sit in the middle of the top shelf or why was it so important a particular tube or a particular laboratory specimen container was carefully positioned on the lower shelf and ONLY on the lower shelf ?

There must have been some underlying reason for this pernickityness but when - as students - we demanded to know why such rigid adherence was required we were usually told that this was either accepted nursing procedure or hospital policy !

But it wasn’t until I was studying psychology during my psychiatric nurse training that I was introduced to some research conducted by Isabel Menzies in 1959 that help me to understand one of the factors that underpinned nurses’ commitment to this sort of ritualised behaviour.

Menzies reminded readers that nurses are continuously confronted by extremely anxiety-producing situations. By definition they are called upon to work with people who are seriously ill, some of whom are likely to die. Many of the tasks that they are called upon to fulfil were (and obviously still are) distasteful and/or repulsive. Wrong decisions have the potential to lead to devastating consequences and, in addition to having to deal with patient’s distress plus their own anxiety, nurses - she noted - also have to respond to the distress of relatives.

Most notably she reported that the way that nursing work was organized seemed directed at containing and modifying these high levels of anxiety. She observed that work practices seemed to encourage the maintenance of a high level of emotional distance between patients and staff. Nurses often performed specialized tasks on a large number of people, e.g. taking the blood pressure of everyone on a ward that required this observation, thereby restricting contact with any one patient. The weight of responsibility for making any final decision making was also mitigated in a number of ways. Even inconsequential decisions were checked and rechecked. Tasks were often "delegated" up the hierarchical ladder with the result that many nurses were doing work well below their competence and position. In some cases subordinates were reticent to make decisions; in others guidelines were not in place to implement delegation.

These processes she argued appeared to act as to work-related mental defence mechanisms.
However whilst they often protected nurses from their original anxieties they sometimes, she said, created new ones. For instance, staff members were given lists of tasks and procedures to fulfil without being given any discretion on how to perform them. Thus trays and trolleys HAD to be set up in the approved way, patients HAD to be woken and given their sleeping pills, patients HAD to be woken early to have their faces washed before breakfast time - despite nurses feeling that they would be better off sleeping. During the research interviews nurses expressed guilt that they were in fact practising bad nursing even though they carried out every procedure to the letter. They realised that quite often they were not responding to the patients’ needs but to the system’s needs.

Menzies argued that substantial elements of the way in which the hospital functioned were underpinned by mechanisms designed to help staff avoid anxiety. The Matron and her staff, she said, made no direct attempt to address these anxiety-provoking experiences nor to develop the capacity of nurses to respond to anxiety in a psychologically healthy way. They did not, for instance, acknowledge that a patient’s death affected nurses or provide support to deal with this and other types of distressing condition. Instead, the rationale developed that a "good nurse" was "detached".

She agreed with psychologists and psychiatrists that if support for anxiety is not provided individuals and will still need to seek out ways of easing the impact of personal stress although - she noted - these were likely to be unconscious and covert and the defences developed against anxiety were likely to become embedded in the organization’s structure and culture.

Most importantly though and using the nurses that she studied Menzies observed that these defences sometimes worked counter to the needs of the primary task. They certainly did not always make sense to the staff and/or the student nurses but since these compulsory behaviours had become part of the organization’s reality, individuals she said, were often faced with the choice of adapting or discontinuing their careers or their training.

Thus several years later the penny dropped for me and I understood some of the fixed nursing rituals and rigid behaviour patterns that I had seen acted-out at Joyce Green more clearly and I appreciated too - perhaps for the first time - what a heavy psychological burdens had been placed upon our young shoulders without any opportunity to talk-though some of the incredibly stressful situations that we came face-to-face with during our days of training.